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Nicholson, Anthony r,- it 3/c NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Anthony Nicholson Male Ai: Date of Death Age If Veteran of U.S. Armed Forces, 04 / 16 / 2018 87 War or Dates N/A Place of Death Hospital, Institution or 344 City, Town or Village Malta Street Address The Home of The Good Shepherd 0 Manner of Death®Natural Cause C Accident Homicide E Suicide 0 Undetermined —Pending US Circumstances —Investigation til Medical Certifier Name Title CI James P. Gaylord MD Address 1184 NY-50, Ballston Lake, NY 12019 pii Death Certificate Filed District Number Register Number City,Town or Village Malta `»~DBurial Date Cemetery or Crematory >:;>: 04 / 16 / 2018 Pine View Crematory fl Entombment Address ECremation Queensbury, NY W Date Place Removed 1❑Removal and/or Held and/or Address --' Hold 0 0 Date Point of Transportation Shipment Es by Common Destination Carrier Mii El Disinterment Date Cemetery Address s' Q Renterment Date Cemetery Address i Permit Issued to Registration Number Name of Funeral Home Compassionate Funeral Care 00364 Riii Address 402 Maple Ave., Saratoga Sp., NY 12866 IiiIi Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ir ILI Permission is hereby granted to dispose of the human remai,�escribec,/bo e s' icated. Iiiii Date Issued 'VI I t \ 70t$ Registrar of Vital Statistics _T% ,,‘ is (signet e) District Number y5(a© Place Malta , New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 114 Date of Disposition 1Ilg(it Place of Disposition ',.U.--- 4-4-1aQ:,. (address) iiii Cr (section) 4 (lot number) (grave number) 01 of Sexton or Person in Charge of Premises •. n,t S+-� fi 2 (p/ ase print) • 1.0 jSignature '^'' Title lt^ 1iutL (over) DOH-1555 (02/2004)